Health Begins at Home: Integrating Public Health Nursing and Legal Services for Community Wellness

Module 4: May 14, 2020

National Nurse-Led Care Consortium

The National Nurse-Led Care Consortium (NNCC) is a membership organization that supports nurse-led care and nurses at the front lines of care.

NNCC provides expertise to support comprehensive, community-based primary care.

– Policy research and advocacy– Technical assistance and support– Direct, nurse-led healthcare services

Housekeeping Items

Question & Answer• Click Q&A and type your questions

into the open field.• The Moderator will either send a

typed response or answer your questions live at the end of the presentation.

Continuing Education Credits• Please take the SurveyMonkey

evaluation at the end of thiswebinar to receive CME/CNE

• You must complete survey to receivecredit.

• Certificate will arrive within 1 weekof completing the survey.

May 14, 2020

SUSTAINABILITY AND EVALUATION

OVERVIEW

Shannon Mace, JD, MPHDirector of Operations, HELP: MLP

TODAY’S PRESENTERS

LEARNING OBJECTIVES

• Increase knowledge on how to evaluate the nursing-legal partnership (NLP) and other medical-legal partnership (MLP)models.

• Increase knowledge of the ways in which MLPs and the NLP are financed.

• Identify promising practices based on peer experiences.

LEARNING COLLABORATIVE WEBINAR #1, #2, #3 RECAP

MISSED THE 1ST & 2ND

WEBINARS?

Webinar and slides are now posted online.

EVALUATING MATERNAL AND CHILD HEALTH MEDICAL-LEGAL PARTNERSHIPS

Vikrum Vishnubhakta, MPH, MBAConsultant/PrincipalForward Consultants

Evaluation Consultant, State of Delaware and Philadelphia NLP

Why Evaluation?May not be popular but is essential.Helps us understand what is working well and what can

be improved in our programming.Helps establish the credibility and strength of MLPs

among state and local agencies.Ultimately helps show the impact of our efforts at the

community and population level.

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Evaluation Design: DelawareMLP services as a method to reduce anxiety and stress

for expectant mothers with low socioeconomic means experiencing legal and social stressors (housing issues, immigration status, etc.).

Enrollees: Expectant mothers experiencing legal and social stressors.

Low SES: Healthy Women, Healthy Babies (HWHB) Sites.

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Evaluation Design: DelawareMethodsEnrollees IdentifiedCompleted Evaluation Tool (R1)Receipt of MLP ServicesComplete Evaluation Tool at Follow-Up (R2)

Time Frame for EvaluationApril 2015 – Present Day

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Evaluation ToolMental Health Inventory (MHI)

38 QuestionsFive Subscales: Anxiety, Cognitive Functioning, Depression, Feelings of Belonging, and Positive Affect

Why: Easy to understand, relevant, simple.

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Current Evaluation Results 15

201 Enrollees Completed R1 54 Enrollees Completed R1 and R2 Surveys

Age:Average: 30 Years

Days Between R1 and R2 Surveys:Average: 196 Days (Min: 1; Max: 1,383)

Evaluation Results 16

Percentage Improvement (All p < 0.05)MHI Overall: +10.7%Anxiety: +10.6%Cognitive Functioning: +9.9%Depression: +11.9%Feelings of Belonging: +7.7%Positive Affect: +12.4%

… numbers are great but comments from enrollees provide greater insights and potential areas for change…

Evaluation Results 17

Can you please tell us how the legal problems you are/were experiencing is/was affecting you in terms of your stress level or health?“I lost my job so I feel very upset and down on myself about it. I don't have any money to pay my bills and my family is poor and can't

help. I'm about to get put out of my home where my children and myself live and I don't have any place to go because I can't afford it. I'm just really sad all the time and no one is there for me. I really need help.”

– Enrollee, 11/16/15

Evaluation Results 18

Can you please tell us how the legal problems you are/were experiencing is/was affecting you in terms of your stress level or health?“[My partner] was trying to take my kids away like I was a bad person; that made me feel very stressful. When I would think about it, my head would hurt and my chest would hurt.”

Did the legal assistance from Community Legal Aid Society, Inc. help you in terms of your stress or health?“Yes, because everything is settled now and I want to thank you all for helping me. I'm not certainly worrying about it now.”

Can you please tell us how it was working with Community Legal Aid Society, Inc.?“It was a good experience, very helpful.” Enrollee, 12/9/15

Evaluation Design: NLP 19

Focus on change in health risk rather than anxiety/stress.

NFP and PAT/MM clients identified as having unmet legal needs (intervention) versus clients without identified unmet legal needs (control).

Investigate the extent of improvement in NFP STAR and PAT LSP domains between intervention and control.

Evaluation Design: NLP 20

NFP treatment showed a significant improvement in 11 out of the 21 STAR domains as compared to the NFP control group and no significant difference in the remaining 10 domains.

PAT treatment group demonstrated a significant improvement in 7 out of the 35 LSP domains and no significant difference in 26 out of the 35 domains; however, the control group fared better on two of the 35 domains.

HEALTH SYSTEMS CHANGE:SUSTAINABILITY AND SCALING

James Teufel, MPH, PhDDirector of Public Health & Associate Professor, Moravian College

Evaluation Consultant

Michael MarmotBest and Worst of Times

On average, populations and places are the healthiest in human history

The inequities in health between populations and places is greatest in human history

Monaco: 89.3 years of life expectancy from birthAfghanistan: 52.8 years years of life

expectancy from birth

Almost 37 years separate the healthiest and unhealthiest country9 years separates the US from the healthiest

Countries Today (2020)CIA World Factbook

Most of the life expectancy gains in the 20th and 21st centuries…Public policy, social, environmental, and

public health innovations

Living conditions and behaviors

~80%

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The United States’ current system seemingly creates health divides

Susan G. Komen Foundation (2020)

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Our Worldin Data(2017)

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Who benefitsamongmen in the UStraditionalmedicalsick caresystem?

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Who benefitsamongwomen in the UStraditionalmedicalsick caresystem?

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Maternal and Child Health

Tied for 55th in the world in maternal mortalityWorse than Russia

Tied for 55th in the world in infant mortality

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Social Policy/Practice and Health Hypothesis

3.8 years of life expectancy among adults could be regained by expanding social welfare program for unemployment, health, and retirement benefitsBeckfield & Bambra, 2016

Is the civil justice system in the U.S. a neglected health system?

Civil Justice Social Determinants

Supplemental Security Income

Income

Eviction or Energy Assistance HousingDiscrimination or Wage Theft Employment

Supplemental Nutrition Assistance Program

Nutrition

Child Support FamilyProtection from Abuse Safety

Medicaid and Social Security Disability Insurance

Insurance

Empowerment and Health EquityMarmot, 2015 & Nazdeek, 2018

Materiale.g., being impoverished

Psychosociale.g., feeling impoverished

Political/Voicee.g., lacking personal or collective agency

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World Justice Project2020 Rule of Law IndexThe United States ranks 109th out of 128

countries in access and affordability of civil justice, between Honduras and Bangladesh.

The United States also ranks 115th out of 128 countries in discrimination in the civil justice system

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We need to change system?

Pluralistic versus Political EconomyMarmot versus Nazdeek

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Vicente Navarro (2009/2010)

“It is not inequalities that kill people,… it is those who are responsible for (or benefit from) these inequalities that kill people.”

Cultural Shift in Valuation

Structures

Processes

Outcomes

Structures

Processes

Outcomes

Structures

Processes

Outcomes

Structures

Processes

Outcomes

Structures

Processes

Outcomes

Structures

Processes

Outcomes

Structures

Processes

Outcomes

Structures

Processes

Outcomes

Structures

Processes

Outcomes

Internal Validity:Efficacy

Duration:Sustainability

Scope:Scaling

Does it work?

Will it continue?

Will it disseminate?

Bigger Question

Who needs to accept that change works and that changes should sustain and scale

We need socially accepted evidence-based changeNot only socially acceptable changeNot only evidence-based change

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Medical-Legal Partnership

Changing traditional medical and legal practiceSystems innovation?

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8 Domains of SustainabilityProgram Sustainability

Assessment Tool

Developed by the Center for Public Health Systems Science of Washington University in Saint Louis

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2.5

3

3.5

4

4.5

5

5.5

Eight Domains of Sustainability

Financial Return on Investment

Medicaid Recovered DollarsRetroactive Medicaid(Teufel, Brown, Thorne, et al, 2009)Helped to build environmental support

within hospitals

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Systems Change

Moving from innovators to the broader social system requires outward facing social connections

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Key items for considerations for typical MLP sustainability

Community leader involvement with local MLPsCommunity involvement in setting MLP goalsDevelopment of communications and marketing that

generate interest and public support for local MLPsDemonstrating value of an MLP to stakeholdersDeveloping long-term financial and sustainability plans

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Partnership

Depth and breadth of partners Community members and

leaders as well as organizationsPartners impact economic, social,

human, and political capital

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Communications

Strategic and operational marketing and messagingPriority audiences segmentedIncrease awareness and demonstrate valueCommunicate value proposition effectively

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Social Return on Investment

Account for material, psychosocial, and political gains

Valuable benefits to the community and/or investorAttempt to monetize benefits when possible to

place on same scale as the monetary investment(Benefits-Costs)/(Costs)

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Traditional Funding

$

ExternalGiving or Philanthropy

Funding Available

Proposals&

Contracts

Internal Investments

External Investments

Benefit Monetary(Hard)

Benefit Non-Monetary(Soft)

Return to Investor(Direct)

(Ben$-Cost$)_______________

Cost$

(Ben -Cost$)________________

Cost$

Return NOT to Investor(Indirect)

(Ben$-Cost$)_______________

Cost$

(Ben -Cost$)________________

Cost$

Systems Funding: SROI

$

OriginatingSupport

FundingAvailable

$

Win External Support

$$

$ $

Social Value

$$

$$$

Strategic Planning

Long-term and future-oriented objectives and strategies are formalized

Operational planning aligns with strategic planning

Planning is integrated into business practices and policies at all levels and in all directions

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Funding Stability

Managing and directing operational budgets Strategically exploring financing

and payer options inside and outside of an organizationStability, diversification, flexibility

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CLOSING THOUGHTS

Katherine Kinsey, PhD, RN, FAANNurse Administrator and Principle Investigator of Philadelphia Nurse-Family Partnership and

Mabel Morris Family Home Visit Program

CLOSING THOUGHTS

Daniel Atkins, EsquireExecutive Director, Delaware Community Legal Aid Society, Inc.

Director, Health, Education, and Legal Assistance Project: A Medical-Legal Partnership

QUESTIONS?

THANK YOU!

Shannon Mace smace@helpmlp.org

Vik Vishnubahkta vikrum@forward-consultants.com

James Teufel teufelj@Moravian.edu

Katherine Kinsey kkinsey@phmc.org

Dan Atkins datkins@helpmlp.org